| Vaccine Brand | |
| Sex | |
| Zip Code | |
| Registered Date |
| Vaccination Date | |
| Coadministered | |
| Coadministered Vaccine |
| Dose 1 Daily | Day0 | Day1 | Day2 | Day3 | Day4 | Day5 | Day6 | Day7 |
|---|---|---|---|---|---|---|---|---|
| Started On | ||||||||
| Duration (mins) | ||||||||
| How are you feeling today? | ||||||||
| Have you had a fever or felt feverish today? | ||||||||
| --> Do you know your highest temperature reading from today? | ||||||||
| --> ---> Enter your highest temperature reading from today (degrees Fahrenheit) | ||||||||
| Have you had any of these symptoms today where you got the shot (injection site)? | ||||||||
| --> Pain | ||||||||
| --> Redness | ||||||||
| --> Swelling | ||||||||
| --> Itching | ||||||||
| --> None | ||||||||
| Have you experienced any of these symptoms today? | ||||||||
| --> Chills | ||||||||
| --> Headache | ||||||||
| --> Joint pain | ||||||||
| --> Muscle or body aches | ||||||||
| --> Fatigue or tiredness | ||||||||
| --> Nausea | ||||||||
| --> Vomiting | ||||||||
| --> Diarrhea | ||||||||
| --> Abdominal pain | ||||||||
| --> Rash, not including the immediate area around the injection site | ||||||||
| --> Any other symptoms or health conditions you want to report | ||||||||
| Did any of the symptoms or health conditions you reported today cause you to | ||||||||
| --> Be unable to work or attend school | ||||||||
| --> Be unable to do your normal daily activities | ||||||||
| --> Get care from a doctor or other healthcare professional | ||||||||
| --> --> Telehealth, virtual health, or email health consultation | ||||||||
| --> --> Outpatient clinic or urgent care clinic visit | ||||||||
| --> --> Emergency room or emergency department visit | ||||||||
| --> --> Hospitalization | ||||||||
| --> --> Other, describe: | ||||||||
| --> None of the above |
| Dose 1 Post Daily | Day14 | Day21 | Day28 | Day35 | Day42 | Day90 | Day180 | Day365 |
|---|---|---|---|---|---|---|---|---|
| Started On | ||||||||
| Duration (mins) | ||||||||
| How are you feeling today? | ||||||||
| Since your last check-in, have you experienced any new or worsening symptoms or health conditions? | ||||||||
| If Yes, Please describe the symptoms or health conditions | ||||||||
| If Yes, Did any of the symptoms or health conditions you reported today cause you to | ||||||||
| --> Be unable to work or attend school | ||||||||
| --> Be unable to do your normal daily activities | ||||||||
| --> Get care from a doctor or other healthcare professional | ||||||||
| --> --> Telehealth, virtual health, or email health consultation | ||||||||
| --> --> Outpatient clinic or urgent care clinic visit | ||||||||
| --> --> Emergency room or emergency department visit | ||||||||
| --> --> Hospitalization | ||||||||
| --> --> Other, describe: | ||||||||
| --> None of the above | ||||||||
| Since your last check-in, did you have a positive COVID-19 test or were you told by a health care provider that you had COVID-19? | ||||||||
| If yes, when were you diagnosed? | ||||||||
| Since your last COVID-19 vaccination, have you had a home or laboratory pregnancy test that was positive? | ||||||||
| How would you describe your current state of health? | ||||||||
| How is your health now compared to your heath before your last COVID-19 vaccination? | ||||||||
| If worse, do you believe your health problems might be related to your COVID-19 vaccination? |
| Vaccination Date | |
| Coadministered | |
| Coadministered Vaccine |
| Dose 2 Daily | Day0 | Day1 | Day2 | Day3 | Day4 | Day5 | Day6 | Day7 |
|---|---|---|---|---|---|---|---|---|
| Started On | ||||||||
| Duration (mins) | ||||||||
| How are you feeling today? | ||||||||
| Have you had a fever or felt feverish today? | ||||||||
| --> Do you know your highest temperature reading from today? | ||||||||
| --> ---> Enter your highest temperature reading from today (degrees Fahrenheit) | ||||||||
| Have you had any of these symptoms today where you got the shot (injection site)? | ||||||||
| --> Pain | ||||||||
| --> Redness | ||||||||
| --> Swelling | ||||||||
| --> Itching | ||||||||
| --> None | ||||||||
| Have you experienced any of these symptoms today? | ||||||||
| --> Chills | ||||||||
| --> Headache | ||||||||
| --> Joint pain | ||||||||
| --> Muscle or body aches | ||||||||
| --> Fatigue or tiredness | ||||||||
| --> Nausea | ||||||||
| --> Vomiting | ||||||||
| --> Diarrhea | ||||||||
| --> Abdominal pain | ||||||||
| --> Rash, not including the immediate area around the injection site | ||||||||
| --> Any other symptoms or health conditions you want to report | ||||||||
| Did any of the symptoms or health conditions you reported today cause you to | ||||||||
| --> Be unable to work or attend school | ||||||||
| --> Be unable to do your normal daily activities | ||||||||
| --> Get care from a doctor or other healthcare professional | ||||||||
| --> --> Telehealth, virtual health, or email health consultation | ||||||||
| --> --> Outpatient clinic or urgent care clinic visit | ||||||||
| --> --> Emergency room or emergency department visit | ||||||||
| --> --> Hospitalization | ||||||||
| --> --> Other, describe: | ||||||||
| --> None of the above |
| Dose 2 Post Daily | Day14 | Day21 | Day28 | Day35 | Day42 | Day90 | Day180 | Day365 |
|---|---|---|---|---|---|---|---|---|
| Started On | ||||||||
| Duration (mins) | ||||||||
| How are you feeling today? | ||||||||
| Since your last check-in, have you experienced any new or worsening symptoms or health conditions? | ||||||||
| If Yes, Please describe the symptoms or health conditions | ||||||||
| If Yes, Did any of the symptoms or health conditions you reported today cause you to | ||||||||
| --> Be unable to work or attend school | ||||||||
| --> Be unable to do your normal daily activities | ||||||||
| --> Get care from a doctor or other healthcare professional | ||||||||
| --> --> Telehealth, virtual health, or email health consultation | ||||||||
| --> --> Outpatient clinic or urgent care clinic visit | ||||||||
| --> --> Emergency room or emergency department visit | ||||||||
| --> --> Hospitalization | ||||||||
| --> --> Other, describe: | ||||||||
| --> None of the above | ||||||||
| Since your last check-in, did you have a positive COVID-19 test or were you told by a health care provider that you had COVID-19? | ||||||||
| If yes, when were you diagnosed? | ||||||||
| Since your last COVID-19 vaccination, have you had a home or laboratory pregnancy test that was positive? | ||||||||
| How would you describe your current state of health? | ||||||||
| How is your health now compared to your heath before your last COVID-19 vaccination? | ||||||||
| If worse, do you believe your health problems might be related to your COVID-19 vaccination? |
| Vaccination Date | |
| Coadministered | |
| Coadministered Vaccine |
| Dose 3 Daily | Day0 | Day1 | Day2 | Day3 | Day4 | Day5 | Day6 | Day7 |
|---|---|---|---|---|---|---|---|---|
| Started On | ||||||||
| Duration (mins) | ||||||||
| How are you feeling today? | ||||||||
| Have you had a fever or felt feverish today? | ||||||||
| --> Do you know your highest temperature reading from today? | ||||||||
| --> ---> Enter your highest temperature reading from today (degrees Fahrenheit) | ||||||||
| Have you had any of these symptoms today where you got the shot (injection site)? | ||||||||
| --> Pain | ||||||||
| --> Redness | ||||||||
| --> Swelling | ||||||||
| --> Itching | ||||||||
| --> None | ||||||||
| Have you experienced any of these symptoms today? | ||||||||
| --> Chills | ||||||||
| --> Headache | ||||||||
| --> Joint pain | ||||||||
| --> Muscle or body aches | ||||||||
| --> Fatigue or tiredness | ||||||||
| --> Nausea | ||||||||
| --> Vomiting | ||||||||
| --> Diarrhea | ||||||||
| --> Abdominal pain | ||||||||
| --> Rash, not including the immediate area around the injection site | ||||||||
| --> Any other symptoms or health conditions you want to report | ||||||||
| Did any of the symptoms or health conditions you reported today cause you to | ||||||||
| --> Be unable to work or attend school | ||||||||
| --> Be unable to do your normal daily activities | ||||||||
| --> Get care from a doctor or other healthcare professional | ||||||||
| --> --> Telehealth, virtual health, or email health consultation | ||||||||
| --> --> Outpatient clinic or urgent care clinic visit | ||||||||
| --> --> Emergency room or emergency department visit | ||||||||
| --> --> Hospitalization | ||||||||
| --> --> Other, describe: | ||||||||
| --> None of the above |
| Dose 3 Post Daily | Day14 | Day21 | Day28 | Day35 | Day42 | Day90 | Day180 | Day365 |
|---|---|---|---|---|---|---|---|---|
| Started On | ||||||||
| Duration (mins) | ||||||||
| How are you feeling today? | ||||||||
| Since your last check-in, have you experienced any new or worsening symptoms or health conditions? | ||||||||
| If Yes, Please describe the symptoms or health conditions | ||||||||
| If Yes, Did any of the symptoms or health conditions you reported today cause you to | ||||||||
| --> Be unable to work or attend school | ||||||||
| --> Be unable to do your normal daily activities | ||||||||
| --> Get care from a doctor or other healthcare professional | ||||||||
| --> --> Telehealth, virtual health, or email health consultation | ||||||||
| --> --> Outpatient clinic or urgent care clinic visit | ||||||||
| --> --> Emergency room or emergency department visit | ||||||||
| --> --> Hospitalization | ||||||||
| --> --> Other, describe: | ||||||||
| --> None of the above | ||||||||
| Since your last check-in, did you have a positive COVID-19 test or were you told by a health care provider that you had COVID-19? | ||||||||
| If yes, when were you diagnosed? | ||||||||
| Since your last COVID-19 vaccination, have you had a home or laboratory pregnancy test that was positive? | ||||||||
| How would you describe your current state of health? | ||||||||
| How is your health now compared to your heath before your last COVID-19 vaccination? | ||||||||
| If worse, do you believe your health problems might be related to your COVID-19 vaccination? |
| Vaccination Date | |
| Coadministered | |
| Coadministered Vaccine |
| Dose 4 Daily | Day0 | Day1 | Day2 | Day3 | Day4 | Day5 | Day6 | Day7 |
|---|---|---|---|---|---|---|---|---|
| Started On | ||||||||
| Duration (mins) | ||||||||
| How are you feeling today? | ||||||||
| Have you had a fever or felt feverish today? | ||||||||
| --> Do you know your highest temperature reading from today? | ||||||||
| --> ---> Enter your highest temperature reading from today (degrees Fahrenheit) | ||||||||
| Have you had any of these symptoms today where you got the shot (injection site)? | ||||||||
| --> Pain | ||||||||
| --> Redness | ||||||||
| --> Swelling | ||||||||
| --> Itching | ||||||||
| --> None | ||||||||
| Have you experienced any of these symptoms today? | ||||||||
| --> Chills | ||||||||
| --> Headache | ||||||||
| --> Joint pain | ||||||||
| --> Muscle or body aches | ||||||||
| --> Fatigue or tiredness | ||||||||
| --> Nausea | ||||||||
| --> Vomiting | ||||||||
| --> Diarrhea | ||||||||
| --> Abdominal pain | ||||||||
| --> Rash, not including the immediate area around the injection site | ||||||||
| --> Any other symptoms or health conditions you want to report | ||||||||
| Did any of the symptoms or health conditions you reported today cause you to | ||||||||
| --> Be unable to work or attend school | ||||||||
| --> Be unable to do your normal daily activities | ||||||||
| --> Get care from a doctor or other healthcare professional | ||||||||
| --> --> Telehealth, virtual health, or email health consultation | ||||||||
| --> --> Outpatient clinic or urgent care clinic visit | ||||||||
| --> --> Emergency room or emergency department visit | ||||||||
| --> --> Hospitalization | ||||||||
| --> --> Other, describe: | ||||||||
| --> None of the above |
| Dose 4 Post Daily | Day14 | Day21 | Day28 | Day35 | Day42 | Day90 | Day180 | Day365 |
|---|---|---|---|---|---|---|---|---|
| Started On | ||||||||
| Duration (mins) | ||||||||
| How are you feeling today? | ||||||||
| Since your last check-in, have you experienced any new or worsening symptoms or health conditions? | ||||||||
| If Yes, Please describe the symptoms or health conditions | ||||||||
| If Yes, Did any of the symptoms or health conditions you reported today cause you to | ||||||||
| --> Be unable to work or attend school | ||||||||
| --> Be unable to do your normal daily activities | ||||||||
| --> Get care from a doctor or other healthcare professional | ||||||||
| --> --> Telehealth, virtual health, or email health consultation | ||||||||
| --> --> Outpatient clinic or urgent care clinic visit | ||||||||
| --> --> Emergency room or emergency department visit | ||||||||
| --> --> Hospitalization | ||||||||
| --> --> Other, describe: | ||||||||
| --> None of the above | ||||||||
| Since your last check-in, did you have a positive COVID-19 test or were you told by a health care provider that you had COVID-19? | ||||||||
| If yes, when were you diagnosed? | ||||||||
| Since your last COVID-19 vaccination, have you had a home or laboratory pregnancy test that was positive? | ||||||||
| How would you describe your current state of health? | ||||||||
| How is your health now compared to your heath before your last COVID-19 vaccination? | ||||||||
| If worse, do you believe your health problems might be related to your COVID-19 vaccination? |